Risk Factors Associated with Carbapenemase-Producing Enterobacterales (CPE) Positivity in the Hospital Wastewater Environment

Abstract

Background: Hospital wastewater is an increasingly recognized reservoir for resistant Gramnegative organisms. Factors involved in establishment and persistence of Klebsiella pneumoniae carbapenemase-producing organisms (KPCO) in hospital wastewater plumbing are unclear. Methods: This study was conducted at a hospital with endemic KPCO linked to wastewater reservoirs and robust patient perirectal screening for silent KPCO carriage. Over five months, both rooms occupied and not occupied by KPCO-positive patients were sampled at three wastewater sites within each room (sink drain, sink P-trap, and toilet or hopper). Risk factors for KPCO positivity were assessed using logistic regression. Whole genome sequencing (WGS) identified environmental seeding by KPCO-positive patients. Findings: 219/475(46%) room sampling events were KPCO-positive in at least one wastewater site. KPCO-positive patient exposure was associated with increased risk of environmental positivity for the room and toilet/hopper. Previous positivity and intensive care unit room type were consistently associated with increased risk. Tube feeds were associated with increased risk for the drain, while exposure to patients with Clostridioides difficile was associated with decreased risk. Urinary catheter exposure was associated with increased risk of P-trap positivity. P-trap heaters reduced risk of P-trap and sink drain positivity. WGS identified genomically linked environmental seeding in six of 99 room occupations by 40 KPCO-positive patients. Interpretation: KPCO-positive patients seed the environment in at least 6% of opportunities; once positive for KPCO, wastewater sites are at greater risk of being positive subsequently. Increased nutrient exposure, e.g. due to tube food disposal down sinks, may increase risk; frequent flushing may be protective. IMPORTANCE: Klebsiella pneumoniae carbapenemase-producing organisms (KPCOs) are bacteria that are resistant to most antibiotics and thus are challenging to treat when they cause infections in patients. These organisms can be acquired by patients who are hospitalized for other reasons, complicating their hospital stay and even leading to death. Hospital wastewater sites, such as sink drains and toilets, have played a role in many reported outbreaks over the past decade. The significance of our research is in identifying risk factors for environmental positivity for KPCOs, which will facilitate further work to prevent transmission of these organisms to patients from the hospital environment.

β-lactam Resistance in Pseudomonas aeruginosa: Current Status, Future Prospects

“…Carbapenemase-producing bacteria have been found in hospital drainage systems (wastewater) and sewage systems and in the general wastewater downstream of hospital treatment systems [216,[275][276][277][278]. This indicates that hospitals may be a large source of the dissemination of carbapenemase-producing isolates into the general environment, providing potential for inter-species gene transfer.…”

Droplets generated from toilets during urination as a possible vehicle of carbapenem-resistant Klebsiella pneumoniae

“…Hospital wastewater is an increasingly recognized reservoir for resistant Gram-negative organisms. Gram-negative bacteria can survive in plumbing (e.g., sink drains, toilets) [ 13 , 14 ].…”

“…The role of sink contamination in transmission is more deeply understood, but studies evaluating the role of toilets in the transmission of MDR organisms are lacking. Park et al recently demonstrated that exposure to CR-KP-colonized/infected patients was associated with environmental (toilet/hopper) CR-KP contamination [ 13 ]. Furthermore, it has been shown that a large amount of bacteria or viruses might remain in toilet bowls after flushing due to adsorption to porcelain, with gradual partial elution occurring after multiple flushes [ 16 – 18 ].…”

Successful eradication of an environmental reservoir of NDM-producing Klebsiella pneumoniae associated with nosocomial transmissions in a low-incidence setting

“…or Acinetobacter spp, as well as CPE, in various settings. (3)(4)(5)(6)(7)(8)(9)(10) Reported outbreaks were characterised by a low overall incidence of clinical cases and highly variable durations, likely due to differences in the speed of detection, the type of measures applied, and the duration of follow-up after their implementation. (11) Cleaning and disinfection protocols or replacement of contaminated equipment often fail to eradicate these environmental reservoirs, leading to long-term transmission of CPE.…”